Download Application of Psychological Strategies for Pain Management in

clinical review
Application of Psychological Strategies for
Pain Management in Primary Care
Kathryn A. Sanders, PhD, Rebecca G. Donahue, PhD, and Robert D. Kerns, PhD
Abstract
• Objective: To review behavioral and cognitive behavioral strategies for pain management and describe
their application in the primary care setting.
• Methods: The biomedical model, gate-control/
neuromatrix theories, and biopsychosocial model for
understanding chronic pain are discussed followed
by a review of behavioral, self-regulatory, and cognitive behavioral treatments and research supporting
their use.
• Results: Operant learning strategies, cognitive
behavioral therapy, hypnosis, and biofeedback have
been shown to improve patients' pain experience;
however, many patients are not engaged in these
treatments. Primary care providers may help prevent
a cycle of pain and disability from occurring by organizing their treatment approach around the idea of
pain management, not pain amelioration. They may
help to promote patient motivation to engage in pain
management therapies through the use of motivational interviewing strategies. Additionally, patientcentered education and counseling in primary care
may facilitate the management of chronic pain.
• Conclusion: Primary care providers can help
patients to manage their pain without an overreliance on medications or medical procedures. They
can help dispel common misconceptions of psychological approaches, help patients set realistic
goals for pain management, provide referrals for
more comprehensive pain management treatment,
and collaborate with other providers managing their
patients’ pain.
A
pproximately 50% of adults in the United States
experience chronic pain [1]. Pain is one of the
most common complaints made to primary care
providers (PCPs) [2,3]. In addition, over $100 billion in lost
productivity and disability per year is attributable to chronic
pain conditions [4]. Unfortunately, despite advancements in
our understanding of physical mechanisms that play a role
in chronic pain as well as the development of sophisticated
assessment and treatment procedures, there is no medical
www.turner-white.com
treatment that consistently alleviates pain for all patients [5].
The lack of consistent and permanent alleviation of pain with
current medical interventions points to the importance of
considering psychological and social factors in an attempt to
understand and treat chronic pain and disability [5]. In this
review, we explore psychological approaches to the management of chronic pain and discuss strategies that primary
care providers can use to promote patient acceptance and
participation in these treatments. We begin by providing a
historical context for the involvement of psychology in the
treatment of chronic pain and review the models of chronic
pain that have shaped our thinking over the past several decades. Next, we review research supporting the use of behavioral, self-regulatory, and cognitive behavioral approaches
to pain management. Finally, we focus on self-management
approaches that can be used in the primary care setting and
discuss how PCPs can use this information when working
with patients with chronic pain.
Models for Understanding Chronic Pain
Biomedical Model
A comprehensive review on this topic has been published
[5]. The field of pain management has been slowly transitioning from a biomedical model of pain to a more comprehensive biopsychosocial understanding of the chronic pain
experience. The biomedical model assumes that a patient’s
amount of pain is proportional to the amount of tissue damage or disease and that treatments to reduce disease activity
or tissue damage will also reduce pain [6]. The major problem with this model is that it ignores the wide variability
in patient reports of pain in response to similar physical
disturbance and treatment. In fact, associations between
physical impairments on the one hand and pain report and
disability on the other are modest at best [5]. Treatment
focuses on correcting the source of pathology or physical
damage. Additional symptoms reported by patients, such as
sleep difficulty, mood symptoms, and impairments in social
or work functioning, are seen as ancillary to the primary
physical complaint and will resolve once the primary issue
From the VA Connecticut Healthcare System, West Haven VA, West Haven,
CT.
Vol. 14, No. 11 November 2007 JCOM 603
pain management
has been resolved. Only after treatment of the underlying
physical pathology has failed to provide pain relief are these
additional factors considered in a causative role. Therefore,
according to this model, symptoms are either biologically or
psychologically caused.
Gate-Control Theory and Neuromatrix Model
In response to criticisms of the biomedical model’s lack of
consideration of the interaction between physical, social,
and psychological factors in pain, Melzack and colleagues
[7,8] developed the gate-control theory of pain. According
to this model, there are 3 systems involved in nociceptive
processing (sensory-discriminative, motivational-affective,
cognitive-evaluative), which interact to produce the patient’s
overall subjective experience of pain through activation of a
gating mechanism in the spinal cord. After debate regarding the physiological evidence for such a model, Melzack [9]
later extended the gate-control theory to a diathesis-stress
model, which he termed the neuromatrix theory. This theory posits that the brain has a neural network that integrates
sensory information, inputs from brain areas responsible for
cognition and emotion, and inputs from our stress-regulation systems [6]. Predispositional factors such as physiological (neural networks, genetics) and behavioral response patterns interact with an inciting pain event to produce stress.
Over time, cognitive processes (eg, worry about the future,
the meaning of pain) contribute to this stress until the pain
becomes a stressor in and of itself. This repetitive and ongoing input leads to structural and functional changes that
may cause altered perceptual processing and contribute
to pain chronicity. At this point, patients may continue to
report pain without any evidence of physical pathology. The
implication of this model is that targeting just one of these
systems will be inadequate due to the multidimensional nature of pain. This model replaces the biomedical model with
a more comprehensive model that includes psychological
and social variables.
Biopsychosocial Model
The biopsychosocial model explains the variety of illness
expression (severity, duration, and effects on the person) by
accounting for the interrelationships among biology, psychological status, and social and cultural contexts [5]. These
factors interact to create each individual’s perception of and
response to pain (ie, their pain experience). In contrast to the
biomedical model, the biopsychosocial model views psychological and social factors not as reactions to disease but
as factors that influence disease severity, maintenance, and
exacerbation. This multifactorial approach to pain management highlights the need to assess which factors play a role
in a patient’s pain and match treatment to address those variables [5]. Psychological and social factors, such as depression,
604 JCOM November 2007 Vol. 14, No. 11
anxiety, beliefs about pain, feelings of controllability, selfefficacy, coping, and social learning, influence pain and disability and are important areas to consider in the assessment
and treatment of chronic pain [5,10]. It is in this area that behavioral and cognitive behavioral approaches to pain management have the most to offer patients with chronic pain.
Behavioral, Cognitive Behavioral, and SelfRegulatory Treatments for Chronic Pain
Operant Learning Model
Fordyce’s [11] operant behavioral treatment was one of the
first psychological interventions for chronic pain. This approach emphasizes social and environmental reinforcing
factors and utilizes principles of reinforcement, punishment,
and extinction to influence patients’ pain-related behaviors.
An operant conditioning model predicts that if others reinforce a patient in pain with attention, sympathy, and other
solicitous responses, the patient will continue to display
pain-related behaviors (eg, reports of pain, moaning, limping, grimacing, guarding, rubbing, use of a cane, increasing
amounts of time spent lying or sitting down, consumption
of medications), even in the absence of continued nociception. In order to decrease the occurrence of these behaviors,
contingent reinforcement needs to be removed and more
adaptive behaviors (eg, exercise and activity) should be
reinforced in their place. Most treatments include use of
time-contingent (rather than pain-contingent) medication
delivery to reduce medication-taking behavior.
There have been several recent reviews and metaanalyses examining the efficacy of operant behavioral treatment for chronic pain associated with a variety of medical
conditions (rheumatoid and osteoarthritis, back pain, limb
pain, and fibromyalgia). In 1 meta-analysis, adequate effect sizes (0.32–1.41) were obtained for operant therapy on
improvements in pain experience, mood/affect, cognitive
coping and appraisal, behavior, and social role functioning
when compared with wait list controls [12]. Effect sizes were
somewhat smaller when compared with active treatment
controls (0.06–0.62). Compas and colleagues [13] reviewed
several studies of patients with rheumatoid disease, headache, irritable bowel syndrome (IBS), and back pain and concluded that operant behavioral treatment for chronic pain
is an efficacious treatment. In a more recent review, there
were no significant differences in outcome between operant
behavioral and cognitive behavioral treatments for chronic
low back pain, but both treatment approaches produced better results than wait list controls or no treatment [14].
Cognitive Behavioral Therapy
The cognitive behavioral perspective on pain and pain
management is informed by the operant model, gate-control
theory, and biopsychosocial model [15]. Central to the
www.turner-white.com
clinical review
cognitive behavioral model is an acceptance of the experience of pain as subjective, covert, and private. According to
this model, individuals’ appraisals, attitudes, beliefs, coping
processes, and problem-solving competence are viewed as
key determinants to the development and perpetuation of
the pain experience, functional disability, and distress [16].
The principle aim of cognitive behavioral therapy (CBT) for
chronic pain is to promote the adoption of a self-management
approach to the experience of pain and its associated problems. Individuals’ commonly experienced sense of helplessness and hopelessness is challenged systematically, and the
development of a more constructive and optimistic problemsolving perspective is encouraged. This reconceptualization
is fostered through a psychoeducational approach to therapy
that encourages the development of an understanding for
the perpetuation of pain, disability, and distress, while challenging erroneous beliefs, fears, and maladaptive avoidance
behavior. The development of an effective self-management
approach is reinforced by a collaborative process that involves
acquisition and practice of a range of cognitive and behavioral
skills [16]. Common components of CBT include (1) patient/
family education regarding models of chronic pain and pain
management, negative effects of health risk behaviors on
pain, sleep hygiene, pain medication effects and intended use;
(2) contingency management/training patients in appropriate
goal setting and reinforcement; (3) relaxation training and/or
biofeedback; (4) problem-solving skills training; (5) training in
effective communication; (6) training in the use of distraction;
(7) behavioral activation incorporating principles of activityrest cycling and pacing; and (8) cognitive restructuring [16,17].
CBT has been reported as an efficacious treatment for a
variety of chronic pain conditions, including chronic pain
syndromes; chronic low back pain; rheumatic diseases such
as osteoarthritis, systemic lupus erythematosus, ankylosing
spondylitis; and IBS [12]. Cognitive behavioral treatments,
in comparison to alternative active treatments, produced
greater changes in pain experiences and cognitive coping
and appraisal and reduced behavioral expression of pain
[12]. With regard to chronic low back pain, CBT was superior to wait list controls at reducing posttreatment pain
intensity and interference in a meta-analysis of treatments
for chronic low back pain [18].
Hypnosis
Hypnosis is generally thought of as a state of highly focused
attention at which time one is susceptible to direct or indirect suggestions to alter awareness, sensations, and affective response to perceptions. Suggestions may be offered
in the form of imagery, relaxation, or meditation strategies
and typically include images of comfort, well-being, and
numbness. These suggestions have been thought of as the
central component of clinical efficacy [19]. Global hypnotic
www.turner-white.com
responsivity and the ability to experience vivid images have
been associated with treatment outcome in hypnosis, progressive muscle relaxation, and autogenic training [20].
However, if a patient is interested in hypnosis or imagery
and has at least some attentional capacity, he or she will
likely benefit from individualized treatment [19].
In a review of 19 controlled trials of hypnosis for several
chronic pain conditions (headache, low back pain, temporomandibular pain disorder, cancer-related pain, sickle cell
disease, fibromyalgia, osteoarthritis, disability-related pain,
and mixed pain disorders), it was found that hypnotic
analgesia produced significantly greater decreases in pain
relative to no treatment, medication management, physical
therapy, and education/advice [20]. These results supported
the conclusions of a previous review of hypnosis as an empirically supported treatment for chronic pain associated
with a variety of conditions [21]. However, the review reported that the effects of hypnosis were similar, on average,
to progressive muscle relaxation and autogenic training [20].
In another review of empirically supported treatments [12],
hypnotherapy was also found to be a potentially efficacious
treatment for IBS pain compared with a psychotherapy plus
placebo medicine control group. A more recent review of
treatments for IBS confirmed these findings, stating that the
evidence points to effectiveness of hypnotherapy as a treatment for IBS [22].
Biofeedback
Biofeedback is a technique in which a patient is trained
to control their body by using feedback from a variety of
monitoring procedures and equipment. During a biofeedback session, a therapist will apply electrical sensors to
different parts of the body to monitor the body’s responses
and feedback auditory or visual cues to alert the patient
to these responses. Once alerted, the patient may begin to
engage in alternative responses (eg, relaxation) to decrease
pain. Patients are typically asked to practice these strategies
at home. It is suggested that biofeedback sessions occur initially twice per week followed by once-weekly sessions for
up to 24 sessions [23].
In treatment of pain disorders, electromyographic (EMG)
and thermal biofeedback have been most utilized. During
EMG biofeedback, disposable sensors are placed on targeted
major muscle groups (forehead, trapezius) to measure muscle
tension. A list of biofeedback strategies are then given to the
patient to choose from when attempting to relax (eg, relaxing imagery, autogenic phrases, deep breathing, awareness of
sensations, mental games, concentrating on auditory feedback,
clearing the mind). During thermal biofeedback, sensors are
attached to fingers to measure skin temperature, and patients
are trained to warm their hands using mental images of warm
sun, watching the meter while directly trying to control it, and/
Vol. 14, No. 11 November 2007 JCOM 605
pain management
or attending to the feeling of blood pulsations in the fingertips
to successfully increase hand temperature [23].
Along with relaxation training, thermal biofeedback has
been called the “standard treatment” for migraine and combined headaches (migraine and tension-type) [23]. EMG biofeedback has also been shown to be successful in reducing
headache activity [23]. In addition to treatment of chronic
headaches, relaxation training and biofeedback have been
reported to maximize treatment effects of multidisciplinary
programs in patients with chronic back pain [24,25]. Furthermore, in a meta-analysis of randomized controlled trials
of chronic pain treatments excluding headache, relaxation
and biofeedback were found to improve pain experience,
mood/affect, cognitive coping, and social role functioning
more than a wait list control in patients with arthritis, back
pain, limb pain, and fibromyalgia [13].
What Can Be Done in Primary Care?
Barriers to Adequate Chronic Pain Treatment
Despite the availability of efficacious psychological treatments for chronic pain, many patients are not successfully
engaged in these treatments, drop out or fail to adhere to
therapist recommendations, or fail to maintain treatment
gains following the completion of treatment [26]. Barriers to
receipt of psychological treatment include patients’ unwillingness to acknowledge the role of stress and mood in their
pain due to the fear that pain will be dismissed as psychological and not treated as real pain; patients’ belief that their
pain is physical and nothing but medications or surgery will
help; and negative attitudes and stereotypes regarding use
of a psychological approach on the part of the patient, significant others, or caretakers [6].
Aspects of the patient-provider relationship can serve as
additional barriers to appropriate pain management. According to 1 review [27], patients with chronic pain and their physicians often have opposing attitudes and goals, with patients
seeking to be understood as individuals and struggling
to have their pain complaints legitimized and physicians
focused on treatment planning that obtains the best clinical
outcome. The authors highlight the importance of the patient
and physician having a shared conceptualization of the patient’s pain experience (ie, biopsychosocial approach) and the
collaborative development of treatment recommendations
based on this conceptualization. Using a biopsychosocial approach, physicians can help their patients with chronic pain
by providing reassurance, encouraging self-management,
and providing referrals when appropriate.
Primary Care: A “Golden Opportunity” for
Appropriate Pain Management
As noted previously, patients’ cognitions, affect, and behaviors play a central role in the pain experience. PCPs may
606 JCOM November 2007 Vol. 14, No. 11
feel ill-equipped to manage these types of issues and subsequently feel they have little to offer patients in this regard
[28]. This can lead to frustration and helplessness on the part
of the physician and the patient. It is difficult for PCPs to
adequately address patients' pain concerns during an office
visit due to several factors [28,29]. Time pressures may not
allow physicians to assess the multidimensional aspects of
the patient’s pain complaint. Over-reliance on the medical
model neglects psychosocial variables that have been shown
to play a role in chronic pain. Extensive use of medical tests
and treatments can lead to patients being more reliant on
the provider and taking less personal responsibility for
their pain management. Lack of clear and consistent guidelines for management of chronic pain and lack of provider
education and clinical expertise in working with chronic
pain patients may contribute to feelings of inadequacy and
helplessness in PCPs.
The first visit with a patient in pain is a golden opportunity to set the stage for the course of treatment [28]. A cycle
of chronic pain and disability can be prevented by good
management from the very beginning of treatment. Patients
should be provided with reassurance, advice, and recommendations for self-management [28]. Reduction in medical
testing, treatment, and attention during the early phase can
prevent chronic problems. Physicians should organize their
treatment approach around the idea of pain management,
not pain amelioration, and ascribe to a stepped-care approach similar to that developed by Von Korff [30].
A Stepped-Care Approach
According to Von Korff’s [30] stepped-care model, the
level and intensity of pain treatment is guided by patient
outcomes while matching interventions to the patient’s
concerns, activity limitations, preferences, and readiness.
In step 1, the least intensive level of care, the PCP provides
patients with information and advice focused on returning
to their usual activities as quickly as possible. Patients' fears
about activity are addressed by explaining the “red flags”
for serious disease and how history and diagnostic information can rule these out, providing information specific
to each patient’s worries, advising patients on appropriate
ways to return to physical activities and benefits of doing
this, and finally, preparing patients for the likelihood of pain
flare-ups in the future. Step 2 typically includes other practitioners (eg, psychologist, physical therapist) and often uses
group formats to assist more moderately impaired patients
in management of their activity limitations. This step usually includes a structured exercise program and cognitive
behavioral strategies to reduce patients' fears. Patients are
assisted in identifying goals and difficulties, planning to
overcome difficulties and achieve goals, increasing motivation for exercise, and gaining support through follow-up.
www.turner-white.com
clinical review
Finally, in step 3, patients who are disabled or are in danger
of becoming disabled receive more intensive management
including additional practitioners in a group or individual
format. Providers work as a team to help patients identify
work difficulties, prescribe an early return to work, engage
the patient in graded exercise and strengthening, and identify and treat any psychiatric comorbidities.
Use of Motivational Interviewing Strategies
Individuals with chronic pain vary in their degree of readi­
ness to adopt a self-management approach. A patient’s readi­
ness is likely predictive of engagement in self-management
therapies and outcome. Jensen [31] and Kerns and colleagues
[32] suggest an adaptation of motivational interviewing
strategies for promoting motivation to engage in pain
management therapies. The stages of change model [33]
conceptualizes patients’ readiness to change behaviors as
moving through several stages: precontemplation, contemplation, preparation, action, and maintenance. Motivational
interviewing [34] applies strategies for decreasing patients’
ambivalence and increasing their motivation for changing
specific health behaviors. It is based on a collaborative, nonconfrontational approach that matches techniques with patients’ current stage of change with an eye towards moving
them in a direction of maintaining a new healthy behavior,
such as self-management of chronic pain (see Jensen [35] for
a review of application of motivational interviewing with
chronic pain patients).
Patient-Centered Counseling in Primary Care
Ockene and Zapka [36] also advocate a patient-centered education and counseling approach that could be adapted for use
in primary care settings to facilitate management of chronic
pain. This physician-delivered approach employs nondirective,
open-ended questioning to elicit active patient participation in
decisions about health behavior change. PCPs follow a stepby-step strategy in which they address a health risk behavior,
assess the patient’s readiness to change their behavior, advise
the patient about the importance of change, assist the patient in
developing and implementing a plan for change, and arrange
for follow-up (the 5 A’s). Personalized information and feedback about the patient’s behavior and health is incorporated.
Motivational interviewing techniques [34] are also commonly
used. Ockene and others have described specific protocols
for effective training of practitioners to employ their patientcentered counseling approach with several health risk behaviors, including smoking, alcohol use, and diet [36–41]. This
could easily be adapted for use in primary care settings with
chronic pain patients. In fact, in 1 unpublished study [42], 89
primary care patients with chronic pain were randomly assigned to 3 treatment groups: treatment as usual/wait list; 10
sessions of CBT with a psychologist; and PRIME-CBT, which
www.turner-white.com
consisted of CBT with a psychologist that included 2 conjoint
sessions with the psychologist and PCP using the 5 A’s approach. They found that both CBT and PRIME-CBT demonstrated significantly greater improvements on measures of
pain, disability, and emotional distress than treatment as usual.
In addition, PRIME-CBT resulted in significantly increased
adherence to weekly homework and goals, greater goal accomplishment, and greater patient satisfaction relative to CBT.
This study provides preliminary evidence that PCP integration
into CBT treatments for pain can be an effective approach to
enhancing compliance and satisfaction with treatment.
In summary, it is clear that PCPs can do much to encourage self-management in their patients with chronic pain,
despite the many barriers to adequate care. In addition,
because of their long-term relationship with the patient,
PCPs are in a unique position to make a referral for more
comprehensive pain management treatment when necessary. Providers can help dispel common misconceptions
regarding psychological approaches to pain management
and help their patients set realistic goals for management
of their pain. Finally, preliminary evidence shows increased
compliance and satisfaction when PCPs work alongside psychologists in managing their patients’ problems with pain.
Conclusion
Research data demonstrate a high rate of chronic pain
among primary care patients as well as a significant relationship between concerns about chronic pain and health
care utilization [43,44]. The goals of primary care are to
provide comprehensive services, improved coordination
and continuity of care, and greater accountability. Encouragement of patients with chronic pain to participate in selfmanagement and reduce reliance on health care resources
is consistent with the goals of primary care. Evidence from
a huge body of research supports the use of behavioral and
cognitive behavioral treatments based on a biopsychosocial
approach to pain management. PCPs can contribute much to
their patients by helping them to manage their pain without
an overreliance on medications or medical procedures. They
can also help during referral of a patient to a psychologist
for CBT by enhancing patients’ motivation, easing patient
concerns regarding seeing a mental health provider, and
ensuring compliance and satisfaction with treatment by
maintaining ongoing involvement in the patient’s care.
Corresponding author: Kathryn A. Sanders, PhD, VA Connecticut
Healthcare System, 950 Campbell Ave., 116B West Haven, CT 06516,
[email protected].
Funding/support: Dr. Kerns is supported by Merit Review grants
from the Department of Veterans Affairs Office of Research and
Development Rehabilitation and Clinical Science Research Services
Vol. 14, No. 11 November 2007 JCOM 607
pain management
and by a grant (no. DF03-035) from the Donaghue Research
Foundation.
Financial disclosures: None.
Author contributions: conception and design, KAS, RGD, RDK;
drafting of the article, KAS, RGD; critical revision of the article, KAS,
RGD, RDK; obtaining of funding, RDK.
References
1. Novy DM. Psychological approaches for managing chronic
pain. J Psychopathol Behav Assess 2004;26:279–88.
2. Gureje O, Von Korff M, Simon GE, Gater R. Persistent
pain and well-being: a World Health Organization Study
in Primary Care [published erratum appears in JAMA
1998;280:1142]. JAMA 1998;280:147–51.
3. Mantyselka P, Kumpusalo E, Ahonen R, et al. Pain as a
reason to visit the doctor: a study in Finnish primary health
care. Pain 2001;89:175–80.
4. National Institutes of Health. The NIH guide: new directions
in pain research. Washington (DC): Government Printing
Office; 1998.
5. Turk DC, Monarch ES. Biopsychosocial perspective on
chronic pain. In: Turk DC, Gatchel RJ, editors. Psychological
approaches to pain management: a practitioner’s handbook.
2nd ed. New York: Guilford Press; 2002:3–29.
6. Keefe FJ, Abernethy AP, Campbell LC. Psychological approaches to understanding and treating disease-related pain.
Annu Rev Psychol 2005;56:601–30.
7. Melzack R, Casey KL. Sensory, motivational and central
control determinants of chronic pain: a new conceptual
model. In: Kenshalo D, editor. The skin senses; proceedings.
Springfield (IL): Thomas; 1968:423–43.
8. Melzack R, Wall PD. Pain mechanisms: a new theory. Science
1965;50:971–9.
9. Melzack R. Pain and stress: a new perspective. In: Gatchel
RJ, Turk DC, editors. Psychosocial factors in pain: critical
perspectives. New York: Guilford Press; 1999:89–106.
10. Simon EP, Folen RA. The role of the psychologist on the
multidisciplinary pain management team. Prof Psychol Res
Pr 2001;32:125–34.
11. Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: Mosby; 1976.
12. Morley S, Eccleston C, Williams A. A systematic review and
meta-analysis of randomized control trials of cognitive and
behavioral therapy for chronic pain in adults, excluding
headache. Pain 1999;80:1–13.
13. Compas BE, Haago DA, Keefe FJ, et al. Sampling of empirically supported psychological treatments for health psycho­
logy: smoking, chronic pain, cancer, and bulimia nervosa.
J Consult Clin Psychol 1998;66:89–112.
14. van Tulder MW, Ostelo R, Vlaeyen JW, et al. Behavioral treatment for chronic low back pain: a systematic review within
the context of the Cochrane Back Review group. Spine
2000;25:2688–99.
15. Turk DC, Meichenbaum D, Genest M. Pain and behavioral
medicine: a cognitive behavioral perspective. New York:
608 JCOM November 2007 Vol. 14, No. 11
Guilford Press; 1983.
16. Kerns RD, Otis J, Marcus KS. Cognitive-behavior therapy
for chronic pain in the elderly. Clin Geriatr Med 2001;17:503–
23.
17. Turk DC. A cognitive-behavioral perspective on treatment of
chronic pain patients. In: Turk DC, Gatchel RJ, editors. Psychological approaches to pain management: a practitioner’s
handbook. 2nd ed. New York: Guilford Press; 2002:138–58.
18. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Metaanalysis of psychological interventions for chronic low back
pain. Health Psychol 2007;26:1–9.
19. Syrjala KL, Abrams JR. Hypnosis and imagery in the treatment of pain. In: Turk DC, Gatchel RJ, editors. Psychological
approaches to pain management: a practitioner’s handbook.
2nd ed. New York: Guilford Press; 2002:187–209.
20. Jensen M, Patterson DR. Hypnotic treatment of chronic pain.
J Behav Med 2006;29:95–124.
21. Hawkins MF. A systematic meta–review of hypnosis as an
empirically supported treatment for pain. Pain Reviews
2001;8:47–73.
22. Blanchard EB. A critical review of cognitive, behavioral, and
cognitive-behavioral therapies for irritable bowel syndrome.
J Cog Psychother 2005;19:101–23.
23. Arena JG, Blanchard EB. Biofeedback training for chronic
pain disorders: a primer. In Turk DC, Gatchel RJ, editors. Psychological approaches to pain management: a
practitioner’s handbook. 2nd ed. New York: Guilford Press;
2002:159–86.
24. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain
treatment centers: a meta-analytic review. Pain 1992;49:221–
30.
25. Loeser JD, Turk DC. Multidisciplinary pain management.
In: Loeser JD, Butler SD, Chapman CR, Turk DC, editors.
Bonica’s management of pain. 3rd ed. Baltimore: Lippincott
Williams & Wilkins; 2000:2069–79.
26. Turk DC, Rudy TE. Neglected topics in the treatment of
chronic pain patients—relapse, noncompliance, and adherence enhancement. Pain 1991;44:5–28.
27. Frantsve LM, Kerns RD. Patient-provider interactions in
the management of chronic pain: current findings within
the context of shared medical decision making. Pain Med
2007;8:25–35.
28. Pruitt SD, Von Korff M. Improving the management of
low back pain: a paradigm shift for primary care. In: Turk
DC, Gatchel RJ, editors. Psychological approaches to pain
management: a practitioner’s handbook. 2nd ed. New York:
Guilford Press; 2002:301–16.
29. Otis JD, Carrington RM, Kerns RD. Multidisciplinary approaches to pain management in primary care settings. In:
James LC, Folen RA, editors. The primary care consultant:
the next frontier for psychologists in hospitals and clinics. Washington (DC): American Psychological Association;
2005:41–59.
30. Von Korff M. Pain management in primary care: an individualized stepped-care approach. In: Gatchel RJ, Turk DC,
editors. Psychosocial factors in pain: critical perspectives.
New York: Guilford Press; 1999:360–73.
www.turner-white.com
clinical review
31. Jensen MP. Enhancing motivation to change in pain treatment. In: Gatchel, RJ, Turk DC, editors. Psychosocial approaches to pain management. New York: Guilford Press;
1996.
32. Kerns RD, Bayer LA, Findley JC. Motivation and adherence in the
management of chronic pain. In: Block AR, Kremer EF, Fernandez
E, editors. Handbook of pain syndromes: a biopsychosocial perspective. Mahwah (NJ): Lawrence Erlbaum. In press.
33. Prochaska JO, DiClemente CC. Transtheoretical therapy:
toward a more integrative model of change. Psychotherapy:
Theory, Research, and Practice 1982;19:276–88.
34. Miller WR, Rollnick S. Motivational interviewing: preparing
people to change addictive behavior. New York: Guilford
Press; 1991.
35. Jensen MP. Enhancing motivation to change in pain treatment. In: Turk DC, Gatchel RJ, editors. Psychological approaches to pain management: a practitioner’s handbook.
2nd ed. New York: Guilford Press; 2002:71–93.
36. Ockene JK, Zapka JG. Physician-based smoking intervention: A rededication to a five-step strategy to smoking
research. Addict Behav 1997;22:835–48.
37. Ockene IS, Hebert JR, Ockene JK, et al. Effects of training and
a structured office practice on physician-delivered nutrition
counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH). Am J Prev Med 1996;12:252–8.
38. Ockene JK, Wheeler EV, Adams A, et al. Provider training
for patient-centered alcohol counseling in a primary care
setting. Arch Intern Med 1997;157:2334–41.
39. Ockene J. Physician-delivered interventions for smoking
cessation: strategies for increasing effectiveness. Prev Med
1987;16:723–37.
40. Pommerenke FA, Dietrich A. Improving and maintaining
preventive services. Part I: Applying the patient path model
[published erratum appears in J Fam Pract 1992;34:398].
J Fam Pract 1992;34:86–91.
41. Manley M, Epps R, Husten C, et al. Clinical interventions
in tobacco control: a National Cancer Institute training program for physicians. JAMA 1991;266:3172–3.
42. Kerns RD, Thorn BE, Otis J. Psychological approaches to
pain management: a primary care perspective. Presented
at the VHA Pain Management Conference: Evolving paradigms: providing health care to transitioning combat veterans; 2007 Apr 10–12; Las Vegas, NV.
43. Caudill M, Schnable R, Zuttermeister P, et al. Decreased
clinic use by chronic pain patients: response to behavioral
medicine interventions. Clin J Pain 1991;7:305–10.
44. Benedetto MC, Kerns RD, Burg MM, et al. Health risk
behaviors and their relationships to health care utilization
among veterans receiving primary medical care. J Clin Psychol Med Settings. In press.
Copyright 2007 by Turner White Communications Inc., Wayne, PA. All rights reserved.
www.turner-white.com
Vol. 14, No. 11 November 2007 JCOM 609